Pre exercise medical questions
Please contact Chloe if there is any details you want to discuss. This is a pregnancy and non pregnancy medical form please complete all fields that apply to you.
Full Name
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First Name
Last Name
Date of birth
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Day
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Month
Year
Date
Phone Number
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area code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Next of kin name
*
Next of kin telephone:
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Gender?
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Male
Female
Other
Prefer not to say
Level of activity
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Not active
Fairly active
Very active
Are you any of the following
Not pregnant
Pregnant
Postnatal
Pre or Post hysterectomy
Please scroll down if the Pre & postnatal, hysterectomy section does not apply to you
Postnatal will apply if you have had any babies
Pre & postnantal, hysterectomy section
Please complete questions below
Please state
pregnant
post partum
Pre or post hysterectomy
If currently pregnant please provide deatils of the following: How many week pregant are you? what is your due date? any previous babies? Any previous miscarages. Are you classed as at risk with your pregnancy?
If you are post partum please answer the following: how old is your baby? how many babies have you had total? when was your recent health visitor check up? were you cleared as healthy and ok to continue with exercise.
This applies to all pregnancies
If you have had a hysterectomy please state how long ago
Was your birth vaginal or c section?
Do you experience any problems or pain with your core or pelvic floor?
Midwife details
Medical questions
for non postnatal clients
Have you had any surgery in the last 2 year? Please provide details below.
Do you suffer with any of the following condition?
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Asthma
Hypermobility
Cancer
Cardiac disease
Diabetes
Hypertension
Epilepsy
Respiratory
Neurological disorder
Osteoporosis
Arthritis
Lymphatic disorder
none
Other
Are you breastfeeding
Par-Q
*
Rows
Yes
No
Has your Dr ever diagnosed you with a heart condition?
Have you ever or do you have pain in your chest when doing activity?
In the past month have you had any pain in your chest?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
If you answered yes to any of the above, please provide more details.
Are you currently taking any medication?
Yes
No
If you do take any medication please list below
Every now and then Chloe may require class photos to be taken for social media and class promotion, Chloe will give you full warning pre photos being taken and these will be stored safely and securely. Do you give permission for photos to be taken and stored?
Yes
No
If you have a Drs consent letter please upload or alternatively please email to Chloe on chloegsportstherapy@gmail.com
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Client liability waiver: In cases where a medical issue is highlighted it is advisable to gain consent from your Dr before starting a exercise programme. Please ensure you have water and a chair close by when taking part in an online live workout. Due to Chloe not physically being able to help you if you do become dizzy or unsteady on your feet, it is advisable someone is in your home with you when taking part in class. Please ensure you listen to your body if you become fatigued and need to rest.I am aware of the risks in observing or participating in the activities offered and sponsored by 'Pilates with Chloe' and I understand that all sports or fitness that I will execute and participate in are entirely at my own risk. I assume complete responsibility and liability for those risks and for the injuries that may occur as a result of these risks, even if injuries occur in a manner that is not foreseeable at the time I sign this agreement. I realise that by voluntarily assuming the risks involved, I will be solely responsible for any loss or damage I sustain, including personal injuries to me, damage to my property, or damage arising out of my death. It is understood that Pilates with Chloe is responsible for any damage that would be resulting from a fault of Pilates with Chloe and its representatives.As part of GDPR Chloe has a legal obligation to protect all your personal information and images taken during group sessions. Please circle to agree for images during sessions to be taken and are happy for them to be used online. All personal information is stored securely.
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Date
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Day
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Month
Year
Date of signature
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